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101 Cards in this Set
- Front
- Back
Extrinsic causes of joint pain
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Neurologic (nerve root compression, herpes), generalized (fibromylagia, polymyalgia, sickle cell), referred pain, and pain originating from surrounding organs
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Intrinsic causes of joint pain
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Articular (arthritis, neoplastic, traumatic), and non-articular such as bursa, tenons, ligaments, muscle
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Signs suggesting an open fracture?
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Continuous bleeding from puncture site or fat droplets in blood
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The four X-ray rule of 2s
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2 sides, 2 views, 2 joints (joint above and below), and 2 times (before and after reduction)
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What is the difference between varus and valgus angulation?
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Varus - apex away from midline; valgus - toward midline
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What are the indications for open reduction? Use the mnemonic NO CAST
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Non-union, Open fracture, Neurovascular Compromise, intra-Articular fracture, Salter-HArris 3,4,5, polyTrauma
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Reasons for splinting?
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Reduces pain and further damage to vessels, nerves, and skin; reduces inadvertently converting closed to open fracture, facilitates patient transport
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What is heterotopic ossification?
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Formation of bone in abnormal locations, such as muscle, secondary to pathology
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What is avascular necrosis?
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Ischemia to bone due to disrupted blood supply; commonly in bones covered by cartilage or with distal to proximal blood supply
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Healing of a fracture at 0-3 weeks?
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Hematoma, macrophages surround fracture site
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Healing of a fracture at 3-6 weeks?
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Osteoclasts remove sharp edges, callus forms within hematoma
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Healing of a fracture at 6-12 weeks?
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Bone forms within the callus, bridging fragments
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Healing of a fracture at 6-12 months?
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Cortical gap is bridged by bone
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Healing of a fracture at 1-2 years?
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Normal architecture is achieved through remodelling
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How do you clinically evaluate healing of a fracture?
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No longer tender to palpation or stressing on physical exam
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How do you evaluate the healing of a fracture with x-rays? (what do you look for?)
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Trabeculae cross fracture site, visible callus bridging site on at least 3 of 4 cortices
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Early local fracture complications
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Compartment syndrome, neurological injury, vascular injury, infection, implant failure, fracture blisters
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Early systemic fracture complications
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Sepsis, DVT, PE, ARDS secondary to fat embolism, hemorrhagic shock
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Late local fracture complications
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Mal/non-union, AVN, osteomyelitis, HO, post-traumatic osteoarthritis, joint stiffness, CRPS type I/RSD
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Orthopedic emergencies? Use the mnemonic VON CHOP
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Vascular compromise, Open fracture, Neurological compromise/cauda equina syndrome, Compartment syndrome, Hip dislocation, Osteomyelitis/septic arthritis, unstable Pelvic fracture
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What is Buck's traction?
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A system of weights, pulleys and ropes that are attached to the end of a patient's bed exerting a longitudinal force on the distal end of a fracture, improving its length, alignment, and rotation
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Emergency measures in open fractures
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Remove obvious foreign material --> irrigate with saline --> cover in sterile dressings --> immediate IV antibiotics --> tetanus or immunoglobulin as needed --> reduce and splint --> NPO and prepare for OR
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Most common route of infection in septic joint?
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Hematogenous
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Most common causes of septic joint in adults?
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Staphylococcus aureus; consider coagulase-negative Staphylococcus in patients with prior joint replacement and Neisseria gonorrhea in sexually active adults
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Risk factors for septic joint
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Age >80, DM, RA, prosthetic joint, recent surgery, skin infects, IVDA, alcoholism
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Clinical presentation of septic joint
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Inability/refusal to bear weight, localized joint pain, erythema, warmth, swelling, pain on active and passive ROM, +/- fever
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Investigations done in suspected septic joint
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X-ray (r/o fracture), ESR, CRP, WBC, blood cultures; joint aspirate, and listen for heart murmur (to r/o endocarditis)
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Treatment of septic joint
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IV antibiotics, empiric therapy, adjust following joint aspirate C&S results; needle aspiration if small, urgent decompression and surgical drainage if large joint
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Plain film findings in septic joint
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0-3 days usually normal; 4-6 days joint space narrowing and destruction of cartilage
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Plain film findings of osteomyelitis
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Soft tissue swelling*, lytic bone destruction*, and periosteal reaction (formation of new bone); *generally not seen until 10-12 days after onset of infection
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Most common organisms causing osteomyelitis
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Staphylococcus aureus; consider Salmonella typhi in sickle cell and Gram negative in neonates and immunocompromised
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Most common route of infection for osteomyelitis
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Hematogenous or exogenous (open fractures, surgery, local infected tissue)
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Common sites of osteomyelitis
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Long bones (children) and vertebra (adults)
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Joint aspirate findings in septic joint
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>80,000 WBCs, protein >4.4, joint << blood Glucose, no crystals and positive Gram stain
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Investigations in suspected osteomyelitis
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Bone biopsy, blood culturem aspirate cultures, ESR; CRP, CBC (leukocytosis; x-ray, bone scan, MRI most sensitive and specific (use for diabetic foot or vertebral involvement)
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Treatment of osteomyelitis
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IV antibiotics, empiric therapy, adjust following blood and aspirate culture results; surgical decortication and drainage +/- local antibiotics if abscess or does not improve after 36 hours on IV antibiotics; worst case amputation
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What is compartment syndrome?
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Increased interstitial pressure in an anatomical compartment (forearm, calf) where muscle and tissue are bounded by fascia and bone with little room for expansion; interstitial pressure exceeds capillary perfusion pressure leading to muscle necrosis (4-6 hours) and eventually nerve necrosis
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The etiology of compartment syndrome can be divided into intracompartmental and extracompartmental. What are the intracompartmental causes of compartment syndrome?
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Fracture (tibial shaft, pediatric supracondylar fractures and forearm), crush injury, and ischemia-reperfusion injury
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The etiology of compartment syndrome can be divided into intracompartmental and extracompartmental. What are the extracompartmental causes of compartment syndrome?
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Constrictive dressing (circumferential cast, poor positioning during surgery), circumferential burn
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Pathogenesis of compartment syndrome
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The 5 P's of compartment syndrome
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Pain, pallor (late finding), paresthesia, paralysis (late finding), and pulselessness (late finding)
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Clinical presenation of compartment syndrome
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Pain with active contraction of compartment and passive stretch, swollen and tense compartment, suspicious history
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Most important sign of compartment syndrome? Symptom?
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Increased pain with passive stretch; most important symptom is pain out of proportion to injury
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Non-operative treatment of compartment syndrome?
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Remove constrictive dressings (casts, splints), elevate limb at the level of the heart
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Operative treatment of compartment syndrome
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Urgen fasciotomy; 48-72 hours post-op - wound closure +/- necrotic tissue debridement
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Investigations in compartment syndrome
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Usually not necessary as it's a clinical diagnosis; measure compartment with catheter after clinical diagnosis is made
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Complications of compartment syndrome
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Rhabdomyolysis, renal failyre secondary to myoglobinuria, Volkmann's ischemic contracture
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Etiology of cauda equina syndrome?
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Compression or irritation of lumbosacral nerve roots below L2; decreased space in the vertebral canal below L2; common causes - herniated disk +/- spinal stenosis, vertebral fracture and tumor
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Clinical features of cauda equina syndrome
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Acute, motor (LMN signs), autonomic signs (urinary and fecal incontinence), sensory - low back pain radiating to legs, bilateral sensory loss or pain, saddle anesthesia, sexual dysfunction
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Treatment of cauda equina syndrome
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urgen investigation and decompression (<48 hours) to preserve bowel, bladder and sexual function and to prevent progression to paraplegia
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Prognosis of cauda equina syndrome
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Improved markedly with surgical decompression; recovery correlates with function at initial presentation: if unable to walk, unlikely to walk after surgery
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What is thoracic outlet syndrome?
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Impingement of subclavian vessels and brachial plexus nerve trunk
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Etiologies of thoracic outlet syndrome
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Congenital - cervical rib, trauma, degenerative - osteoporosis, arthritis
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Clinical features of thoracic outlet?
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Neurogenic (ulnar and median nerve motor and sensory), arterial (fatigue, weakness, coldness, ischemic pain, paresthesia), venous (edema, venous distention, collateral formation, cyanosis)
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Treatment of thoracic outlet syndrome
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Conservative - physiotherapy, posture and behaviour modification, surgical - removal of first or cervical rib
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Mechanism of anterior hip dislocation
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Posteriorly directed blow to knee with hip widely abducted
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Management of hip dislocation
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Examine for neurovascular injury --> reduce hip dislocation ASAP (<6h) to decrease risk of AVN of the femoral head -> hip reduction for 6 weeks post-reduction
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Clinical features of anterior hip dislocation
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Shortened, abducted, externally rotated limb
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Treatment of anterior hip dislocation
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Closed reduction under conscious sedation/GA, post-reduction CT to assess joint congruity
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Mechanism of posterior hip dislocation
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Severe force to knee with hip flexed and adducted; e.g., knee into dashboard in a motor vehicle collision (MVC)
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Clinical features of posterior hip dislocation
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Shortened, adducted and internally rotated limb
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Treatment of a posteriorly dislocated hip
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Closed reduction under conscious sedation/GA only if associated femoral neck fracture; ORIF if unstable, intra-articular fragments or posterior wall fracture; post-reduction CT to assess joint congruity and fractures; if reduction is unstable, put in traction for 4-6 weeks
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Most common type of hip dislocation
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Posterior
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Mechanism of central hip dislocation
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Traumatic injury where femoral head is pushed medially through acetabulum
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Possible complications of all hip dislocations
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Post-traumatic osteoarthritis, AVN, fracture of femoral head, neck, or shaft; sciatic nerve palsy in 25% (10% permanent), HO, thromboembolism - DVT/PE
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What are the four joints in the shoulder?
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Glenohumeral, acromioclavicular (AC), sternoclavicular (SC), and scapulothoracic
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Factors causing shoulder instability
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Shallow glenoid, loose capsule, ligamentous laxity
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Shoulder passive ROM
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Abduction - 180; adduction - 45; flexion - 180; extension - 45; internal rotation - level of T4; external rotation - 40-45
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Describe the Rochester method to reduce dislocations
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Patient lies supine with hip and knee flexed on injured side; surgeon stands on patient's injured side; surgeon passes one arm under patient's flexed knee, reaching to place that hand on patient's other knee; with other hand, surgeon grasps patient's ankle on injured side, applying traction, while assistant stabilizes pelvis; reduction via traction, internal rotation, then external rotation once femoral head clears acetabular rim
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What is the most commonly dislocated joint in the body?
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The glenohumeral joint, since stability is sacrificed for motion
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Prognosis of shoulder dislocation
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Recurrence rate depends on age of first dislocation: <20 - 65-95%; 20-40: 60-70%; >40: 2-4%
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Specific complications of shoulder dislocation
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Rotator cuff or capsular tear, shoulder stiffness; injury to axillary nerve/artery, brachial plexus; recurrent/unreducted dislocation (most common complication)
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Mechanism of anterior shoulder dislocation
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Abducted arm is externally rotated/hyperextended, or blow to posterior should; involuntary, usually traumatic; voluntary, atraumatic
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Symptoms of anterior shoulder joint dislocation
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Pain, arm slightly abducted and external rotated with inability to internally rotate
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Findings on shoulder exam in anterior shoulder dislocation
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"Squared off" shoulder, positive apprehension tests, positive relocation test, positive sulcus sign
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What is considered a positive apprehension test?
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Patient looks apprehensive with gentle shoulder abduction and external rotation to 90 degrees since humeral head is pushed anteriorly and recreates feelings of anterior dislocation
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What is considered a positive relocation test?
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A posteriorly directed force applied during the apprehension test relieves apprehension since anterior sublluxation is prevented
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What is considered a positive sulcus sign?
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Presence of subacromial indentation with distal traction on humerus indicates inferior shoulder instability
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Investigations in suspected anterior shoulder dislocation
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X-rays: AP, trans-scapular, and axillary views
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Radiographic findings in anterior shoulder dislocation
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Axillary view: humeral head is anterior; trans-scapular/scapular Y view: humeral head is anterior to the centre of the "Mercedez-Benz sign"
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What is a Hill-Sachs lesion?
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Compression fracture of posterior humeral head due to forceful impaction of an anteriorly dislocated humeral head against the glenoid rim
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Treatment of anterior shoulder dislocation
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Closed reduction with IV sedation and muscle relaxation; obtain post-reduction x-rays; check post-reduction NVS; sling for 3 weeks (avoid abduction and external rotation), followed by shoulder rehabilitation (dynamic stabilizer strengthening)
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Mechanism of posterior shoulder dislocation (5%)
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Adducted, internally rotated, flexed arm; FOOSH; 3 E's (epileptic seizure, EtOH, electrocution); blow to anterior shoulder
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Clinical features of a posterior shoulder dislocation
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Arm is held in adduction and internal rotation; external rotation is blocked; anterior shoulder flattening, prominent coracoid, palpable mass posterior to shoulder; posterior apprehension ("jerk") test
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What is posterior apprehension test?
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With patient supine, flex elbow 90 degrees and adduct, internally rotate the arm while applying a posterior force to the shoulder; patient will "jerk" back with the sensation of subluxation
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Investigations in suspected posterior shoulder dislocation
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X-rays: AP, trans-scapular, axillary
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AP x-ray findings on posterior shoulder dislocation
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Partial vacancy of glenoid fossa and >6mm space between anterior glenoid rim and humeral head (positive rim sign), humeral head may resemble a lightbulb due to internal rotation (lightbulb sign)
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Axillary x-ray findings on posterior shoulder dislocation
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Humeral head is posterior
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Trans-scapular view findings on x-ray in posterior shoulder dislocation
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Humeral head is posterior to centre of "Mercedez-Benz sign"
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Other x-ray findings in posterior shoulder location
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Reverse Hill-Sachs lesion (75% of cases): divot in anterior humeral head; reverse bony Bankar lesion: avulsion of the posterior glenoid labrum from the bony glenoid
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Treatment of posterior shoulder dislocation
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Closed reduction, obtain post-reduction x-rays, check post-reduction neurovascular status, sling in abduction and external rotation for 3 weeks, followed by shoulder rehablitation
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Muscles of the rotator cuff
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SITS: Supraspinatus, Infraspinatus, Teres minor, Subscapularis
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How do you screen out rotator cuff tears?
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No night pain (SN 87.7%); No painful arc (SN 97.5%); No impingement signs (SN 97.2%); no weakness
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Describe the traction-countertraction method of reducing a shoulder dislocation
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Assistant stabilizes torso with a folded sheet wrapped across the chest while the surgeon applies gentle steady traction
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Describe the Stimson method of reducing a shoulder dislocation
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While patient lies prone with arm hanging over table edge, hand a 5lb (2.3kg) weight on wrist for 15-20 minutes
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Describe the Hippocratic method of reducing shoulder dislocations
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Place heel into patient's axilla and apply traction to arm; perhaps the safest method of shoulder reduction
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Nerve root of biceps reflex
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C5/C6
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Nerve root of the brachioradialis reflex
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C6
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Nerve root of the triceps reflex
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C7/C8
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Nerve root of the patellar reflex
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L2-L4
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Nerve root of the ankle jerk reflex
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S1/S2
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